Provider Demographics
NPI:1770914202
Name:MACASERO, JOEL (NP)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:MACASERO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5373
Mailing Address - Country:US
Mailing Address - Phone:209-409-3199
Mailing Address - Fax:
Practice Address - Street 1:1234 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5373
Practice Address - Country:US
Practice Address - Phone:209-409-3199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23830363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner